2. CASE PRESENTATION DR SHARJEEL SARFRAZ AHMED SHEIKH DEPARTMENT OF UROLOGY AND RENAL TRANSPLANTATION RAWALPINDI MEDICAL COLLEGE/BENAZIR BHUTTO HOSPITAL RAWALPINDI

5. PATIENT’S PROFILE CR NO : 12792 NAME : MUHAMMAD RAFIQUE FATHER’S NAME : ALLAH BUX AGE : 48 SEX : M ADDRESS : VILLAGE TALLI BHATTIAN,SHAH NIQDAR, JHANG PH NO : 0343-1001497 CNIC NO : 33202-0591661-7 DOA : 02/07/2015 MOD : OPD

6. PRESENTING COMPLAINTS RIGHT FLANK PAIN : 07 YRS

7. SIGNS AND SYMPTOMS SUDDEN IN ONSET SEVERE IN INTENSITY RADIATES TOWARDS BACK ASSOCIATED WITH NAUSEA & VOMITING RELIEVED BY INJ. ANALGESICS

8. PAST MEDICAL HISTORY H/O APPENDICECTOMY : 1992 H/O HOMEOPATHIC DRUGS INTAKE FOR STONE DISEASE 04 yrs HTN,IHD,DM..NIL NKDA

9. PERSONAL HISTORY DRIVER BY PROFESSION MARRIED FOR 20YRS WITH NO ISSUE CIGARRETTE SMOKER : 02 PACKS / DAY OCCASIONAL CHARAS ADDICT LOW SOCIO-ECONOMIC STATUS

10. GENERAL PHYSICAL EXAMINATION PULSE : 70/MIN BP : 120/80 mmHg TEMP : 98.6 F R/R : 12 / MIN THYROID LYMPH NODES EDEMA PALLOR JAUNDICE

11. ABDOMENAL EXAMINATION RIF SCAR MARK FOR APPENDICECTOMY RT INGUINO SROTAL REDUCIBLE SWELLING (RIH) REST UNREMARKABLE

12. INVESTIGATIONS COMPLETE BLOOD COUNT – Hb : 13.8 – TLC : 5.7 – PLT: 277 RENAL FUNCTION TESTS – UREA : 28 – CREATININE : 0.8

13. LIVER FUNCTION TESTS – BILIRUBIN:0.7 – ALT:43 – ALKALINE PHOSPHATASE :68 PT/APTT : NORMAL ANTI HCV :NEGATIVE HBsAg :NEGATIVE BLOOD GROUP : B +VE

14. ULTRASONOGRAPHY RIGHT RENAL CALCULUS MEASURING 2.7CM IN THE RENAL PELVIS CAUSING MODERATE HYDRONEPHROSIS

16. X RAY KUB LARGE RADIO OPAQUE SHADOW SEEN IN THE RIGHT RENAL AREA

18. INTRA VENOUS UROGRAPHY RIGHT RENAL CALCULUS WITH HUGE PELVIS CAUSING MODERATE DILALATION OF THE PELVICALYCEAL SYSTEM EXCERETING THE CONTRAST

20. PRE OPERATIVE PREPARATION ANESTHESIA FITNESS TAKEN CONSENT TAKEN NPO AFTER MIDNIGHT I/V CANNULA 18 G INSERTED 01 PINT OF BLOOD ARRANGED

21. PROCEDURE RIGHT PERCUTANEOUS NEPHROLITHOTOMY ( PCNL )

22. DATE OF SURGERY 07/07/2015 GENERAL ANESTHESIA GIVEN 5 FR OPEN ENDED RETROGRADE URETERIC CATHETER PASSED CYSTOSCOPICALLY UPTO THE PELVICALYCEAL SYSTEM IN DORSAL LITHOTOMY POSITION

23. RETROGRADE URETERIC CATHETRIZATION

24. THEN PATIENT WAS SHIFTED INTO COMPLETE PRONE POSITION SCRUBED AND DRAPED AGAIN

25. IMAGE OF DRAPE

26. KIDNEY PUNCTURE

27. RETROGRADE CONTRAST MEDIA (UROGRAFIN) INJECTED THROUGH URETERIC CATHETER OPACIFING THE PELVICALYCEAL SYSTEM RIGHT LOWER POLE POSTERIOR CALX WAS PUNCTURED WITH 18 G NEEDLE UNDER FLOUROSCOPE GUIDANCE

29. VIDEO OF PUNCTURE

31. INSERTION OF GUIDE (GLIDE ) WIRE

34. DILATATION OF TRACT

35. TRACT DILATED WITH SERIAL METALLIC (ALKIN’S) DILATORS OVER THE OLIVE GUIDE ROD UPTO 21 FR

37. AMPLANTZ SHEATH 24 FR

40. NEPHROSCOPY

42. NEPHROSCOPE OF 21 FR INTRODUCED THROUGH THE AMPLANTZ SHEATH STONE ALMOST 4 CM IN SIZE WAS VISUALIZED IN THE HUGE BAGGY RENAL PELVIS

44. INSITU LITHOTRIPSY WITH PNEUMATIC LITHOCLAST

46. RETRIEVAL OF STONE FRAGMENTS

48. STONE FRAGMENTS

49. IRRIGATION AND WASH

53. COMPLETE STONE CLEARANCE

56. NEPHROSTOMY

58. NEPHROSTOMY PLACED AT THE END OF PROCEDURE GUIDE WIRE REMOVED WOUND CLOSED WITH SILK 2/0 SINGLE STITCH ASEPTIC DRESSING DONE URETERIC CATHETER WAS FIXED WITH 16 FR FOLEY CATHETER

59. POST OPERATIVE CARE NEPHROSTOMY WAS CLAMPED ON NEXT DAY NEPHROSTOMY WAS REMOVED ON 2 nd POD AFTER GETTING POST OPERATIVE X-RAY KUB URETERIC CATHETER ALONG WITH FOLEY CATHETER REMOVED ON 3 rd POD I/V ANTIBIOTICS WERE CONTINUED FOR THREE DAYS PATIENT WAS DISCHARGED ON 3 RD POD STITCH REMOVED ON 7 TH POD

60. BLOOD TRANSFUSION BLOOD TRANSFUSION WAS NOT REQUIRED DUE TO MINIMAL LOSS

61. POST OPERATIVE X RAY KUB

62. PICTURE OF WOUND

63. GOING HOME

64. THANK YOU